|
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION [229668]
|
Facility
|
IP
|
$2,561.60
|
|
|
Service Code
|
CPT J1303
|
| Hospital Charge Code |
NDG229668A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,408.88 |
| Max. Negotiated Rate |
$2,049.28 |
| Rate for Payer: Cash Price |
$1,152.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2,049.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,536.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,408.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,921.20
|
|
|
RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION [229668]
|
Facility
|
OP
|
$2,561.60
|
|
|
Service Code
|
CPT J1303
|
| Hospital Charge Code |
NDG229668A
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,408.88 |
| Max. Negotiated Rate |
$1,921.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1,536.96
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1,536.96
|
| Rate for Payer: Cash Price |
$1,152.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$1,536.96
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1,536.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1,408.88
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1,921.20
|
|
|
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]
|
Facility
|
IP
|
$61.86
|
|
|
Service Code
|
CPT J2785
|
| Hospital Charge Code |
1796133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.02 |
| Max. Negotiated Rate |
$49.49 |
| Rate for Payer: Cash Price |
$27.84
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$49.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$37.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$46.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE [91408]
|
Facility
|
OP
|
$7.20
|
|
|
Service Code
|
CPT J2785
|
| Hospital Charge Code |
1796133
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.96 |
| Max. Negotiated Rate |
$5.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$4.32
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$37.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$37.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$4.32
|
| Rate for Payer: Cash Price |
$27.84
|
| Rate for Payer: Cash Price |
$3.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$37.12
|
| Rate for Payer: Health Smart Auto/Commercial |
$4.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$37.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$4.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$34.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.96
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$46.40
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$5.40
|
|
|
RELUGOLIX 120 MG TABLET [229912]
|
Facility
|
OP
|
$104.15
|
|
|
Service Code
|
NDC 72974-120-01
|
| Hospital Charge Code |
ERX229912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.28 |
| Max. Negotiated Rate |
$78.11 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$62.49
|
| Rate for Payer: Aetna of CA Government/Medicare |
$62.49
|
| Rate for Payer: Cash Price |
$46.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$62.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.11
|
|
|
RELUGOLIX 120 MG TABLET [229912]
|
Facility
|
IP
|
$104.15
|
|
|
Service Code
|
NDC 72974-120-01
|
| Hospital Charge Code |
ERX229912
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$57.28 |
| Max. Negotiated Rate |
$83.32 |
| Rate for Payer: Cash Price |
$46.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$83.32
|
| Rate for Payer: Health Smart Auto/Commercial |
$62.49
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$57.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$78.11
|
|
|
REMDESIVIR 100 MG/20 ML (5 MG/ML) IV SOLN (FOR PTS 40 KG OR MORE) [228088]
|
Facility
|
IP
|
$31.20
|
|
|
Service Code
|
CPT J0248
|
| Hospital Charge Code |
NDG228088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$24.96 |
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.40
|
|
|
REMDESIVIR 100 MG/20 ML (5 MG/ML) IV SOLN (FOR PTS 40 KG OR MORE) [228088]
|
Facility
|
OP
|
$31.20
|
|
|
Service Code
|
CPT J0248
|
| Hospital Charge Code |
NDG228088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$23.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.72
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.40
|
|
|
REMDESIVIR 100 MG/20 ML VIAL - COMMERCIAL PRODUCT [4082058624]
|
Facility
|
IP
|
$31.20
|
|
|
Service Code
|
CPT J0248
|
| Hospital Charge Code |
NDG228088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$24.96 |
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.40
|
|
|
REMDESIVIR 100 MG/20 ML VIAL - COMMERCIAL PRODUCT [4082058624]
|
Facility
|
OP
|
$31.20
|
|
|
Service Code
|
CPT J0248
|
| Hospital Charge Code |
NDG228088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.16 |
| Max. Negotiated Rate |
$23.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.72
|
| Rate for Payer: Cash Price |
$14.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$23.40
|
|
|
REMDESIVIR 100 MG LYOPHILIZED POWDER FOR INJECTION - COMMERCIAL PRODUCT [4082058626]
|
Facility
|
IP
|
$685.78
|
|
|
Service Code
|
CPT J0248
|
| Hospital Charge Code |
ERX4082058626
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$377.18 |
| Max. Negotiated Rate |
$548.62 |
| Rate for Payer: Cash Price |
$308.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$548.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$411.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$377.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$514.34
|
|
|
REMDESIVIR 100 MG LYOPHILIZED POWDER FOR INJECTION - COMMERCIAL PRODUCT [4082058626]
|
Facility
|
OP
|
$685.78
|
|
|
Service Code
|
CPT J0248
|
| Hospital Charge Code |
ERX4082058626
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$377.18 |
| Max. Negotiated Rate |
$514.34 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$411.47
|
| Rate for Payer: Aetna of CA Government/Medicare |
$411.47
|
| Rate for Payer: Cash Price |
$308.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$411.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$411.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$377.18
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$514.34
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
IP
|
$73.55
|
|
|
Service Code
|
NDC 67457-198-03
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.45 |
| Max. Negotiated Rate |
$58.84 |
| Rate for Payer: Cash Price |
$33.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.16
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
IP
|
$77.17
|
|
|
Service Code
|
NDC 63323-723-03
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$61.74 |
| Rate for Payer: Cash Price |
$34.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$57.88
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
OP
|
$73.55
|
|
|
Service Code
|
NDC 67457-198-03
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.45 |
| Max. Negotiated Rate |
$55.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$44.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$44.13
|
| Rate for Payer: Cash Price |
$33.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$44.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.16
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
OP
|
$73.50
|
|
|
Service Code
|
NDC 0143-9391-10
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.42 |
| Max. Negotiated Rate |
$55.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$44.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$44.10
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$44.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.12
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
OP
|
$73.55
|
|
|
Service Code
|
NDC 67457-198-00
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.45 |
| Max. Negotiated Rate |
$55.16 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$44.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$44.13
|
| Rate for Payer: Cash Price |
$33.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$44.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.16
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
IP
|
$73.55
|
|
|
Service Code
|
NDC 67457-198-00
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.45 |
| Max. Negotiated Rate |
$58.84 |
| Rate for Payer: Cash Price |
$33.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.45
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.16
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
OP
|
$73.50
|
|
|
Service Code
|
NDC 0143-9391-01
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.42 |
| Max. Negotiated Rate |
$55.12 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$44.10
|
| Rate for Payer: Aetna of CA Government/Medicare |
$44.10
|
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$44.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.12
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
IP
|
$77.17
|
|
|
Service Code
|
NDC 63323-723-01
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$61.74 |
| Rate for Payer: Cash Price |
$34.73
|
| Rate for Payer: Cigna of CA HMO/PPO |
$61.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$57.88
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
IP
|
$73.50
|
|
|
Service Code
|
NDC 0143-9391-01
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.42 |
| Max. Negotiated Rate |
$58.80 |
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.12
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
IP
|
$73.50
|
|
|
Service Code
|
NDC 0143-9391-10
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.42 |
| Max. Negotiated Rate |
$58.80 |
| Rate for Payer: Cash Price |
$33.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$58.80
|
| Rate for Payer: Health Smart Auto/Commercial |
$44.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.42
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$55.12
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
OP
|
$77.17
|
|
|
Service Code
|
NDC 63323-723-01
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$57.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$46.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$46.30
|
| Rate for Payer: Cash Price |
$34.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$46.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$57.88
|
|
|
REMIFENTANIL 1 MG INTRAVENOUS SOLUTION [18398]
|
Facility
|
OP
|
$77.17
|
|
|
Service Code
|
NDC 63323-723-03
|
| Hospital Charge Code |
1737066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.44 |
| Max. Negotiated Rate |
$57.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$46.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$46.30
|
| Rate for Payer: Cash Price |
$34.73
|
| Rate for Payer: Health Smart Auto/Commercial |
$46.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$46.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.44
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$57.88
|
|
|
REMIFENTANIL 2 MG INTRAVENOUS SOLUTION [18400]
|
Facility
|
IP
|
$147.10
|
|
|
Service Code
|
NDC 67457-198-99
|
| Hospital Charge Code |
1737067
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.90 |
| Max. Negotiated Rate |
$117.68 |
| Rate for Payer: Cash Price |
$66.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$117.68
|
| Rate for Payer: Health Smart Auto/Commercial |
$88.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$80.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$110.32
|
|
